REPUBLIC OF THE 

PHILIPPINES )
Municipality of Sergio Osmeňa Sr., ) SS.
X-----------------------------------------------X

AFFIDAVIT OF LOSS

I, SEMPROSA PATA ARENDA, Filipino, of legal age, married, and a resident of

Penacio, Sergio Osmeňa Sr.,, Zamboanga del Norte under oath hereby depose and
state:

1. THAT I am a registered owner/holder of a ATM card, being a

grantee/beneficiary of Pantawid Pamilyang Pilipino Program (4 PS) of the
Department of Social Welfare and Development (DSWD);
2. THAT sometimes on January 24, 2021 somewhere in Antonino, Sergio
Osmeňa, Zamboanga del Norte , I discovered that I lost my wallet which
contain my ATM card and other Identification Cards and cash amounting
Thirteen Thousand Pesos (13,000), more or less ;
3. THAT I exerted diligent efforts to locate the said ATM card but to no avail and
I therefore considered the same as lost and can no longer be found;
4.  THAT I am executing this Affidavit to attest to the truth of the foregoing facts,
for the re-issuance of a new ATM card and for whatever legal purpose it may
serve.

IN WITNESS WHEREOF, I hereunto affix my signature this 7 th day of February

2021 at Sergio Osmeňa, Zamboanga del Norte, Philippines.

SEMPROSA PATA ARENDA

Affiant
VIN: 7214-0052A-H0169RAA10000

SUBSCRIBED AND SWORN to before me this 7th day of February 2021 at

Sergio Osmeňa, Zamboanga del Norte, Philippines, affiant exhibited to me her valid
proof of Identity as above-stated.

ATTY. EARL RUSSELL S. PAULICAN

Notary Public
Until December 31, 2021
Roll No. 75530
PTR No. 2185126, 01/04/2021, Dipolog City
TIN # 472-022-138
Notarial Commission No. SN: ZDN-DPL-042-2020

Doc No. ________;

Page No. _______ ;
Book No. _______;
Series of 2021.